<?php
        require_once('../auth/auth.php');
?>

<html lang="en">

<head>	
<?php 
$page_title = "Add Patient";
include 'patientPortalTemplate.php' 
?> 
</head>

<body>
	<section id="main" class="column">
<!--		
		<h4 class="alert_info">Welcome to the free MediaLoot admin panel template, this could be an informative message.</h4>
		<h4 class="alert_warning">A Warning Alert</h4>
		<h4 class="alert_error">An Error Message</h4>		
		<h4 class="alert_success">A Success Message</h4>
		      
-->		
		<div class="clear"></div>
		
		<article class="module width_full">
			<header><h3>Add New Patient</h3></header>
				<div class="module_content">
				<form name="addPatientForm" action="db/addPatientDB.php" method="post">
						<fieldset style="width:100%;float:center margin-right: 3%;"> <!-- to make two field float next to one another, adjust values accordingly -->
							<label>Title</label>
							<input type="text" style="width:97.5%;" name="title">
						</fieldset>						
						
						
						<fieldset style="width:48%; float:left; margin-right: 3%;"> <!-- to make two field float next to one another, adjust values accordingly -->
							<label>First Name</label>
							<input type="text" style="width:92%;" name="firstname">							
						</fieldset>
						
						<fieldset style="width:48%; float:left;"> <!-- to make two field float next to one another, adjust values accordingly -->
												
							<label>Last Name</label>
							<input type="text" style="width:92%;" name="lastname">

						</fieldset><div class="clear"></div>
						
						
						<fieldset style="width:48%; float:left; margin-right: 3%;"> <!-- to make two field float next to one another, adjust values accordingly -->
							<label>Gender</label>
							<select style="width:92%;" name="gender">
								<option>Select One</option>							
								<option>Male</option>
								<option>Female</option>							
							</select>						
						</fieldset>
						
							<fieldset style="width:48%; float:left;"> <!-- to make two field float next to one another, adjust values accordingly -->
												
							<label>Age</label>
							<input type="text" style="width:92%;" name="age">

						</fieldset><div class="clear"></div>												
					
						<fieldset style="width:48%; float:left; margin-right: 3%;"> <!-- to make two field float next to one another, adjust values accordingly -->
							<label>Zipcode</label>
							<input type="text" style="width:96%;" name="zipcode">

						</fieldset>
						
						<fieldset style="width:48%; float:left;"> <!-- to make two field float next to one another, adjust values accordingly -->
												
							<label>Primary Disease</label>
							<select style="width:97.5%;" name="primary_disease">
								<option>Select One</option>							
								<option value="CHF">Congestive Heart Failure</option>
								<option>Diabetes</option>
							</select>												
												
						</fieldset><div class="clear"></div>						

						<div class="clear"></div>
				</div>
			<footer>
				<div class="submit_link">
					<input type="submit" value="Add" class="alt_btn">
					<input type="reset" value="Clear">
				</div>
			</footer>
		</form>
		</article><!-- end of post new article -->

</body>

</html>
